General Info

Email

Occupation

What is your occupation?

General Dietary Practice

General Health

Current and History of Health

Do you have any pre-existing medical conditions (e.g., diabetes, heart disease)

Please describe briefly any physical or health conditions or diagnoses.

Do you have any family history of obesity or related health issues?

Please briefly describe.

Are you taking any medication? If so, please list them.

Other Health Information

Feel free to share if there is any other health related updates you feel it is important to know.

Natal Information

Birth City, State/Province, Country

Time of Birth

If you know your time of birth, please mark. If you do not know or need time to research, then email Judy once you know. Thank you.

The Body

Body Type

If your pronoun differs from your biological male/female category, please review the choices and select what best matches. If any edits are needed, we can address/correct this at a later time. Thank you.

Additional Body Type

Which body type best describes your current body?

Blood Type

If you do not know your blood type or would like to research and submit later, feel free to email Judy once you find out.

Goals of the Program

Would you like to lose or gain weight?

Body Weight

What is your current body weight in pounds. Please just put in number.

10 % Goal - Lose or Gain Weight

What is your 10% of body weight loss/gain goal? For example, if you weigh 200 pounds, 10% is 20 pounds.

Short-Term Goal Weight

In pounds, what is your short-term weight goal by the end of the 6-month program? Just type in number, versus "xx lb".

Long-term Weight Goal

What is your long-term weight goal? (at least one - two years of sustaining)

Additional Goals, Intentions & Expections

Besides weight, do you have any other goals or intentions for the program? What are your expectations during and after the program? What do you hope to gain, learn, change, or strengthen?

Family History & Current Household

Family History - Father's side of the family lineage

Please briefly describe any physical or psychological health conditions or trauma of the father's family lineage that you are aware of.

Family History -Mother's side of the family lineage

Please briefly describe any physical or psychological health conditions or trauma of the mother's family lineage that you are aware of .

Number of Siblings Plus You

What was the total number of siblings and including you. Please type only a number response. (Ex. If you have 4 siblings plus you, then type "5". If you are an only child, type "1". )

Siblings

Please describe where you are in the sibling order.

Siblings History or More Info

If the siblings construct is/was a little more complicated, please describe.

Other Family information

Please feel free to share if there is any other information regarding family history or dynamics that may be important to know.

Current Family Household

Please share your current family construct and dynamic.

Motivation of Weight Loss/Gain

Motivation

What have your practiced and implemented thus far for trying to reach your goal weight, currently and in the past?

Any Challenges?

What are the biggest challenges you have in losing/gaining weight/maintaining weight loss/gain?

Why this 6-Month Program?

What motivated you to sign up for this program?

Consent & Disclaimer

DISCLAIMER: I, the recipient, understand that Pranic Healing is not meant to replace conventional medicine but rather to complement it. If symptoms persist a medical professional is to be consulted immediately. I hereby release the person(s) providing Pranic Healing and the Pranic Healing organization from any liability as a result of the services received by me.

Please submit name as an electronic signature below

The 10% Pilot Project

initial Intake & Consent form